Contralateral approach to giant ruptured and unruptured ophthalmic artery aneurysms: patient series

Abstract

Background: Giant ophthalmic artery (OphA) aneurysms remain surgically challenging despite the progress in endovascular treatments. This study describes the contralateral interoptic corridor in select patients based on imaging criteria suitable for clipping. The aim of this study was to show that despite the growing use of novel endovascular techniques, such as coil embolization and flow diversion, for the treatment of OphA aneurysms, microsurgical clipping may still be preferred for giant ones under certain conditions.

Observations: The authors retrospectively reviewed the records of the microsurgical treatment of unruptured and ruptured giant OphA aneurysms at the University Hospital Center "Mother Teresa," Tirana, from 2007 to 2016. Four patients were selected for microsurgery and the contralateral approach using ophthalmic evaluations and coronal imaging on computed tomography, magnetic resonance imaging, and digital subtraction angiography that demonstrated aneurysms with a small neck and an orientation between 11 and 13 on the coronal clock face. A prefixed chiasm was a contraindication to this approach.

Lessons: Giant OphA aneurysms can be safely clipped through a contralateral interoptic corridor without creating new visual deficits or a residual aneurysm. https://thejns.org/doi/10.3171/CASE2473.

Keywords: giant paraclinoid aneurysms; microsurgical clipping; ophthalmic artery; vascular disorders.

FIG. 1.

A: Bone-window MPR study confirming a calcium-free neck. B: CT angiography MIP study showing a small neck. C: MRI study showing an intra-aneurysmal thrombus with a dome orientation at 11−13 o’clock on the coronal clock face. D: DSA study, dome and neck projection. E: Three-dimensional DSA study of the OphA neck with the OphA visible. The hypophyseal arteries and other small branches are not detectable. F: MRI study showing the postfixed chiasm and aneurysm neck.

FIG. 2.

A: Case 1. A 45-year-old female underwent a right pterional craniotomy for a left OphA aneurysm. B: Excluded aneurysm through an optic sandwich clipping. C: Case 2. A 48-year-old male underwent a right pterional craniotomy for a left OphA aneurysm. The black arrowindicates hypophyseal branches. D: Clipping with preservation of small vessels around the neck. The black arrowindicates hypophyseal branches. E: Case 3. A 57-year-old female underwent a right pterional craniotomy for a left OphA ruptured aneurysm. F: Clipping with straight 11-mm Yasargil clips. G: Case 4. A 41-year-old male underwent a left pterional craniotomy for a right OphA aneurysm. Thewhitearrow indicates the OphA. H: Superior position of the right OphA in relation to the aneurysm neck. The white arrow indicates the OphA.

FIG. 3.

A: Postoperative anteroposterior DSA study showing exclusion of a left OphA aneurysm with a sandwich clip and the contralateral pterional craniotomy. B: Postoperative lateral DSA study. C: Postoperative 3D DSA study showing the clip and the OphA. D: Postoperative 3D DSA study showing the aneurysm clip exclusion without remnants with preservation of the OphA and small branches.